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Original Report |
1 Department of Pediatric Radiology, Cliniques Universitaires Saint Luc, 10,
avenue Hippocrate, Brussels B1200, Belgium.
2 Department of Pediatric Pneumology, Cliniques Universitaires Saint Luc,
Brussels, Belgium.
Received June 7, 2004;
accepted after revision August 13, 2004.
Address correspondence to R. Menten.
Abstract
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CONCLUSION. The outer appendiceal diameter of 6 mm or more cannot be considered a reliable criterion for the diagnosis of acute appendicitis in patients with cystic fibrosis.
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Graded compression sonography has proved to be an effective aid in the diagnosis of acute appendicitis [2]. The conclusions of many studies have led to the wide acceptance of the size criterion for the outer diameter of the normal appendix as smaller than 6 mm [3-5] or 6 mm or smaller [6]. The aim of our study was to show that this criterion is not reliable in patients with cystic fibrosis.
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Examinations were performed on both HDI 3500 and HDI 5000 units (Philips Medical Systems) with L12-5 probes (using Philips SONO-CT Real-Time Compound Imaging, when available). Evaluation of the appendix was performed using the technique of graded compression described by Puylaert [2]. The outer cross-sectional anteroposterior section of the appendix was measured at its greatest distance between the outer borders of the outer muscle coat (Fig. 1).
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The mean diameter of the appendix was significantly larger in patients lacking sufficient pancreatic enzyme (pancreatic-insufficient group) (7.4 ± 2.3 mm) than in pancreatic-sufficient patients (5.3 ± 1.8 mm, p = 0.006). In the pancreatic-sufficient group, four patients (40%) had an appendiceal diameter of 6 mm or larger; 40 patients (71%) in the pancreatic-insufficient group had an appendiceal diameter of this size.
We also categorized the subjects by age groups using the cutoff age between
pediatric and adult medicine patients in our hospital—15 years. The
appendix was seen in 40 (89%) of 45 patients younger than 15 years and in 26
(79%) of 33 patients 15 or older. The difference was not statistically
significant. The mean appendiceal diameter was 7.1 mm (6.7 mm for patients
< 15 years and 7.7 mm for patients 
15 years; the difference was not
statistically significant).
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As in our experience, recent articles present an important improvement due to technologic advances and increased radiologist experience in sonographic assessment of the gastrointestinal tract in the visualization of the normal appendix in contrast with the results provided by Birnbaum and Wilson [5] in a noncystic fibrosis-specific adult population: 0-4% in their own experience and in that of others [6, 8]. In a mixed adult and pediatric population with cystic fibrosis, Hahn et al. [9] described an enlarged appearance of the appendix (mean, 9.8 mm) in a study performed between 1990 and 1996, identifying the appendix in 20% (12/59) of the patients.
The findings of an enlarged appendix in patients with cystic fibrosis patients has been described in relation to abnormal changes such as a marked increase in goblet cells, distention with a mucus line, dilated crypts, and the presence of numerous lymphoid follicles [1, 10, 11].
Like Kessler et al. [3] and Rettenbacher et al. [4], we measured the outer diameter of the appendix rather than the appendiceal wall thickness because the luminal limit of the mucosal layer may be difficult to identify, especially in case of a deep pelvic appendiceal tip. The measurements were performed under maximal compression, easily obtained in all our patients in the absence of right lower quadrant pain. In noncystic fibrosis-specific populations, Rettenbacher et al. described 6% of symptomatic patients without acute appendicitis as having an appendiceal diameter of 6 mm or larger, whereas Kessler et al. reported finding a diameter of this size in only one of 104 patients. In their control group, Rettenbacher et al. reported finding an appendiceal diameter of 6 mm or larger in 23% of the patients.
We found a diameter of 6 mm or more in 67% of the patients in whom the
appendix was identified. We found a diameter of this size in more than 50% of
both the pediatric (60%) and adult (77%) groups. The mean appendiceal diameter
was larger than 6 mm in both groups (6.7 mm in patients < 15 years and 7.7
mm in patients 15 years). We should note that if one sets the cutoff
point at 7 mm, 52% of the subjects have diameters that are larger than that
size (39% for a cutoff point set at 8 mm).
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Our findings do not support the hypothesis of a simple relation between pancreatic enzyme therapy and the thickening of the appendix.
Despite the fact that it is well known that one cannot use the outer diameter of the appendix alone to make the diagnosis of acute appendicitis, this criterion remains the first and most commonly known and used. We have shown that this criterion is not at all reliable in a population of patients with cystic fibrosis, even as a minor criterion, to aid in diagnosis.
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